03100194 CITY OF CUPERTINO h'*' f� *ms'' �Yy,
BUILDING DIVISION - PER ONTOWCTORJA`�1\ R1V1 k\ g
BUILDING ADDRESS: PROBERT WOLFF PERMITN(03100194
62 NOVEMBER D
OWNER'S NAME: PERMIT ISSUE DATE
PROBERT WOLFF 10/27/2003
NE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER; BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
10 LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions or Chapter 9(commencing Job Description
with Sonoran 7")of Division 3 of the Business and Professions Code.and my license is
inmBmnetradaffeel. SHOWER UPGRADE
j3K License Class - Lic.M
it- Dau Contractor
g ARCHITECTS DECLARATION 'I
fB understand my plain shall bromides politic fccorJs /�/�/���
eC.
.�� Licensed Pmfessiunal - 0�
5 OWNER-BUILDER DECLARATION
aM 1 hereby mbrm that 1 am exempt from me Contractor's License Law for the
a O following noon.(Section 71131.5,Business and Professions Code:Any city or county
I.
m which requires a permit to conswm,¢Iter,improve,demolish.or repair any structure $1500
poor as its issuance.also equina the applicant for such permit to file a signed statement
< that he is licensed random to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
(commencing with Section 70DO)of Division 3 of the Business and Professions Codi or
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of 36216035 . 00
Section 7031.5 by any applicant for a permit subjects me applicant u a civil penalty of ane APN Number Occupancy Type
net mora man Eve hundred dollars(S500). P Y YP
❑I,as no,of the germy,or my employcea with wages six orientate compensation,
will do the work,and to structure is not intended oreRered for sale(Sea TO44,Business
and Professions Code:The Contractor's License Law don not apply a an owner of Required Inspections
property who builds or improves mcomn.and who deassuch work himselforthrough his
own employeos,provided that such improvements are not intended Incanted forule.If.
however,the building or improvement is sold within one year of completion,me owner.
builder will have the burden of proving mat he did not build or improve for purpose of
sale.).
Cl 1,as owner Df me Property,am exclusively compacting with licensed contractors to
construct the project(Sec.IOM,Business and Professions Code:)The Conuutor'a Li.
cense Law docs not apply to an owner of progeny who bobla or improve tppai and
who contracts far such projcce with a conteemr(')lice sed puma Ito tM Conmaor's
Li nu Law.
l am exam oder Sec. ,B&PCfor thle mods
az '
O r Data46
WORKER' COMP NSA N ECe IO
I hereby affirm un der penalty of pcj.,one of the flowing declarations:
1 have and will maintain aCeNGcate of Consent to self-insure for Wmklara Compen.
satlon,u provided for by Section 37M of the Labor Code,far me performance If the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
37W of the Labor Code,for the perfarmance,of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This uetismneed oat hecompleed if the rermit is Rome hundred dollan(SIBIB
or les.)
1 certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any Come,an as a become suhjecuo the Workers'Compensation
laws of California.Dae
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
�O forthwith comply with such urvotinna or this con iuhalt be deemed revoked.
y�y CONSTRUCTION LENDING AGENCY
I hereby affirm that mere is a Construction lending agency I'nr the perfermance of
Y. Mame work far which this permit is issued(Sec.3RD.Civ,C.)
Q L¢ndcr's Name
y ILndefa Md..
;)LQ I mnify that I have read this application and sum that the above information is
N Cortem.1 agree to comply with all city and county ordinances and state laws relating to
�U building construction,and hereby authorize representatives of this city to enter upon me -
G 'hove-mentioned pererty for inspection purposes.
r (We)agree a save,indemnify and keep harmless the City of Cupertino against
Wl liabilities,judgmanu,costs and expenss ewhich may in any way¢come against said City
J in consequence of the gntiag of this permit. J
APPLI ANT LINDERST No AND IL COMPLY WITH ALL NON-POINT Issued by: Date
SE RF/iltt,ATl Y /�,"
till eLf1- �Z-03 Re-roofs
1,1 Ignattecof Apploamucte acwr
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will me applicant or future building occupant store or handle haaafdous material
as conned by the Cupertino Municipal_Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)7
❑Ya �Nu All roofs shall be inspected prior to any roofing material being installed.
'
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it haraodious air contaminants as Claimed by the Bay Arca Air Quality Management all new materials for inspection.
suiC T ���///
❑Yes pp No
1 have mad the ha mbilins materials requirements under Chapter b,95 of the Califon
nim Health&S dicty Code,Sado¢25505,25533 and 25534.1 undersund mat if the building
docs not to. I y have a mount,the it is my maponsihility lI nnJl'y tM Pont of me
rcyuirem hwh' mustx�netPon ,i IearacerdEeamoracdp�n Signature of Applicant Date
't>wn p ate' tnoixed,ge%I`�1 pj All roof coverings to be Class"B"or better
OTWER-BUILDER VERIFICATJ#4
1. (Check one) I or my immediate family (parent,spouse or child) will perform
• A. All the work authorized by this permit
B. A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
• portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm, Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reve ee ss*dde).
Property Owner's Signati r - R/ 7 D3
Job Address:
l B t2 Permit# G �L
AM changes to the information provided on this forst shall be submitted to the City of Cupertino Build
Department.
1
City of Cupertino Building Department
CITY OF 10300 Torre AvenuAlft
C' I P E kT I N O Phone: (408)777-3
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself,you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.Si Small`Business Administration). For more specific information about your
obligations under state law,contact the`Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own_ employees,without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material.
personally. 'Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned. i
Very truly yours,
Building Department,
City of Cupertino
f �
Printed on Recycled Paper
WITY OF CUPERTINO* 3 l
CITY OF PERMIT APPLICATION FORM
CUPEQ INO
PN# f _ O Date:
Building Address: L Mailing Address (if d' ferent om building address):
06111a Bz f
Owner's Name: v �� O Phone#:
Contractor: License#:
l
Contact: Phone: Cupertino Business License#:
Fax:
Building Permit Info:
Bld ect ❑ P Mech ❑
Job Description:
Residential ❑ o e ial
Sq.Ft. Floor Area: $/ .Ft.:
Cost of Project: �� O cupancy Group: �7
Type of Construction: Please check this bx if the proje rs a
second-storyadditi0
•
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> I OOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V<= IOOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investi ation fee BUILDING
BMITIGATC Comm. Housin Mit. Fee BUILDING
I of �p�
`ITY OF CUPERTINO
CUPS 14 F PERMIT APPLICATION FORM
uanti Fee ID Fee Description Fee Group
IMF BMITIGATR Res. Housing Mit Fee BUILDING
BMNEWMULTI New Multi-Family Res MECHANICAL
BMNEWSF&2F New Sf&2F Res Bldgs MECHANICAL
BNEWMULTI Multifamily Res ELECTRICAL
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BNUMULTI New Multifamily Res PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pblg Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
19- BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER Install/Alter Water Pie PLUMBING
BPWHEATER Water HeaterNent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREN AIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREM3USWAY Remodel Busways ELECTRICAL
BREMFIXT Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace> l OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
2 of 3
� I
S OITY OF CUPERTINO*
CUP TYOF O PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group
BREMRECEPT Rc tl Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issuance PLUMBING
PPLBG I Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
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CITY OF CUPERTINO 2 g
BUILDING DIVISION PERMIT ,,CONTRACTOR INFORMATION:`rl
BUILDING ADDRESS: PROBERT WOLFF PERMIT NCO.
62 NOVEMBER3100194
-RS NAME: PERMIT ISSUE DATE
DROBERT WOLFF 10 27/2003
E:
SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECrI
s
0, LICENSED CONTRACTOR'S DECLARATION
1 botany affirm that 1 Am limned under provisions of Chapter 9 ocommencina Job Description
.�m with Section 9001)of Division 3 of Ute Business and Professions Code,and in,license 1,
iq_a Lbc.AcClfall rceamerrec` SHOWER UPGRADE
Liccnu ss, Lich
it
Data ARCHITECTS DECLARATION
f W U 1 understand my plans shall W used as p.hire records
6
�0 UccnuJ Pndcsstonal
i
OWNER-BUILDER DECLARATION g 1 hereby affirm I ammmcaenicmpr from the Contractor's License Low for the
p O following mason.Section 7031.5,Business and Professinm Calc:Any city or county
m wbich mquirn a permit m construct,alter improve,demolish,or repair any structure 15 0 0
-ga Priono itsissuance.also mquirea the applicant(orsuch remit Glc a signed statement
mat he is licensed pursuant to the previsions or the contractors License Law(Chapter9 Sq.Ft. Floor Area Valuation
r$ $ (commencingwiInSCeion7000)of Division 3nfineBusineuand Professions Code)ter 36216035 . 00
.- Nat he is exempt Ihemfrom and the bun for don alleged exemption.Any violation of
Section 7031.5 by any applicant for A permit subjccu the applicant to a civil penalty of
not more than five hundred della,,(SSW). ApN Number Occupancy Type
0 1,u owner of Ibe proper,m my employees with wages u their sole compensation,
will do the work,and the ameture is no,Intended or offered far sal.(See.7044,Business
and Professions t m
Cad.:The Conte ;nt, License Law docs apply an mater of rRequired Inspections
progenywho builds de improves Ihereohandwho does such woor himselfarmuah his
own employees,pmvided that such irepotinmenn are not intended moRered forsale.If,
however.Ne building or improvement is sold within one year of cnmpkahm.the owner. ` /
builder will have the burden d proving that he did not Wild or improve for puryou of / `� /f
❑s a, her of project
progeny,am exclusively contracting with licensed canmeters to /
consumer the es nor (Sec.7044.Business and Professions Cade)The Contractor.rad
Whoa law dote not apply loan owner of progeny who Wilds or improves thereon,and
wba se La turnouts,Bir such pmjecu with.eonuutar(s)lim ted pursuant to the Conuacnra
LI rate law. 77
l am exam oder Sec. .0&PCT,
Dam
WORKER' COMP NSA N ECL�10 "
1 hereby affirm under penalty of perjury one of the Il., decluatiosu:
an and will maintain a CcniGmate of Consent m seiGit¢ure for Worker's Compere
s.Iran,ex provided for by Section 3]00 of the Labor Code,for the pnrfnrmanca of the
work for which this permit is issued.
0 1 have and will maintain Worker;Compensation insurance,u requited by Section
3700 of the Labor Code,for Ne pmfurmmce of Ne work for which his pemtit is issued. '
My Workers Compensation Insurance carrier and Policy number art:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if Ibe,amid 1,formic hundred Bullar,(S Ni
tar los.) '
1 ccnify that in the perfoom.,ec of the work for which this permit is issued,10.110
employ any roo on in any manner An ac to Wcume subjuua the Warkers'Comgemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,alter making this Ccnificem of Exemption,you should
WcOom subject to the Worker s Cma,mintim provisions of Ne Labour Code,you must
�Q forthwith comply with such pm,minn,or this permiuhall W deemed revoked.
C7 CONSTRUCTION LENDING AGENCY
1 hereby affirm that Boom is•conswninn lending agency tar the Performance or
the work fur which this permit i,issued(Sec.3M,Civ,C.)
YLender's Name
3 z Lambe,Address
)Q I ccnify that 1 have read this application and Sinai that the above information is
i F correct.l agree to comply with All city and county ordinances and ante laws rtlating to
�U building construction.and hereby amhonae representatives of this city n enter upon the
>~t31 ahovememionedpmgeny rorimpeamA whichporticoes.
ti LL (We)agree te$ave,indemnify and keep harmless the City of Cupefllao.,br t
V! incoili mini ents.of
granting
uind of this ewhich may in any way accrue against said City
)x inrnnsegmnce of tae gaming of this permit .(
^ APPLI ANT UNDERSTp ND ANDIL OMPLY WITH ALL NON-POINT V
so Rr u Arlglfs. / Issued by: Date d
6fj(( d a 03
tuna re of A,iiestnuContrecmr Re-roofs
HAZARDOUS MATERIALS DISCLOSURE ale Type of Roof
Will the applicant or future building Occupant store or handle hazardous material
Ijn.,
Broad by IW CupertinoMunicipal Code,Chapter 9.13,and Ne Health and Safety
tioSecn]5532(x)?Ely. @Na All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment ror devicm which If a roof is installed without first obtaining an inspection,I agree to remove
harardnus air contaminants as defined Ay be Bay Arca Air Quality Management all new materials for inspection.
ct? ,,��//O Yes pd Nu
1 have mad Ne h3modouus`ma efols requirements under Chamer6.95 ofthe Califonulth Si SafetyCode,$ecdam 25505,25533.nit 25534.1 undcrstond natifthe Wilding
currently base a tenant Nm I,is rcaponciAilitymnnul ytW eta min l of Ne
hhl ti Ur a Wird muss b of gnu o f c of a Ccnlfcam of Occupan
a 03 Signature of Applicant Date
fin manvadsent Date All roof coverings to be Class "B"or better